Health Care/Joan Retsinas

Health Insurance: On the Electoral Brink

You think the Affordable Care Act, for all the flaws attributed to it, is basically secure - much as you assumed Roe v. Wade was basically sure?

It is just as vulnerable to changes that would decimate it.

Candidate Donald Trump has promised something better, without articulating what that better might entail

We can see, though, the damage he inflicted on the Affordable Care Act while in office — damages that have been hard to undo. In his four years, he didn’t kill it, but wounded it. In this election, “health insurance” pops up below-the-fold in newspapers, barely rating a few lines compared to abortion, the economy, the wars in Gaza and the Ukraine. Health insurance rarely makes it to press conferences, and inspires few op-eds. So it is so easy to overlook the harm Candidate Trump wreaked, as well as the harm he might inflict.

The Brookings Institution, reviewing the Trump era “changes” to the Affordable Care Act (“Trump, the Administrative Presidency, and Federalism”) called the changes “sabotage” — an apt descriptor. The key wounds:

1) Decreasing the outreach necessary for enrollment. To enroll, people must know about the Act, and understand the that at last this Act will give them affordable comprehensive insurance. Poor people are accustomed to, and leery of, scams. This Act was genuine. But the Trump Administration cut back funds for outreach.

2) Cutting the subsidies to private insurers to participate. The Act was predicated on the participation of private insurers. “Obamacare” was not government insurance, but government-subsidized, regulated insurance, open to people who could not get coverage from their employers.

3) Allowing cheaper, poorer alternatives to the ACA plans. Those Obamacare plans require 10 essential benefits, set caps on payments, and nixed the pre-existing condition clauses that were devastating to millions of Americans, pre-Obamacare. But President Trump allowed short-term and employer-sponsored, cheaper plans that left people who got sick -- who became patients — “underinsured.”

4) The “work-waivers” that states could impose on Medicaid enrollees. Common sense argued that requiring people who were ill to work to have insurance to pay for treatment was irrational, as well as cruel; but the Trump enthusiasts blessed “work requirements” anyway.

The ultimate danger to the ACA lay in the Supreme Court, which might have cancelled it. Fortunately, the Court let the ACA stand.

Now, as part of the proposed great new plan the Trump campaign promises: insurance that lets people buy the coverage they think they need. A healthy non-smoking 25-year-old man (who does not risk getting pregnant) may decide he needs a barebones policy — no frills, no exhaustive coverage for hospitalization, no significant time for rehabilitation, minimal pharmaceutical coverage. That man willingly, happily, pays less for less coverage. In contrast, that man’s 55-year-old smoker father might opt for a more comprehensive, and more expensive, policy, to cover his possible stroke, his lung cancer, his arthritic knee. If this sounds simplistically stupid, it is. The 25-year-old non-smoker will age, needing more coverage for the illnesses and mishaps that may well beset him. The point of an insurance pool is to cover the population, to spread the expense. To work, a pool needs those healthy people — the non-users — to pay premiums. Pre-Obamacare, states tried “high risk pools” to cover the people that insurers didn’t want. Not surprisingly, those pools proved too costly for states.

Before the Affordable Care Act, the nation had millions of people without insurance, and millions more with poor insurance. Those are the bad old days that the Trump Administration would bring back.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email joan.retsinas@gmail.com.

From The Progressive Populist, November 1, 2024

Populist.com